Method and apparatus for measuring and treating shivering during therapeutic temperature control

ABSTRACT

Methods and apparatus for the prevention and treatment of shivering encountered during therapeutic temperature regulation are disclosed that utilize an active system of counterwarming such that the timing and intensity of warmth provided to selected body areas is regulated dynamically in response to such factors as the extent of cooling applied to the core, the degree of shivering encountered, and patient temperature. Additionally, methods and apparatus are disclosed for the measurement and quantification of shivering for use in this and other applications.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a Divisional of U.S. application Ser. No.12/575,708, titled “Method and apparatus for measuring and treatingshivering during therapeutic temperature control”, which was filed Oct.8, 2009, and which claimed the benefit of Alexander Calhoun Flint U.S.Provisional Application No. 61/103,815, titled “Method and apparatus foractive counterwarming and shivering quantification to treat and measureshivering during therapeutic temperature control”, which was filed Oct.8, 2008; and of Alexander C. Flint U.S. Provisional Application No.61/176,015, titled “Method and apparatus for measuring and treatingshivering during therapeutic temperature control”, which was filed May6, 2009. Each of the said applications is incorporated herein byreference.

BACKGROUND

1. Field of the Invention

This invention relates to therapeutic temperature regulation and,particularly, to controlling shivering during maintenance ofnormothermia or induced hypothermia.

2. Description of Related Art

Therapeutic induction of hypothermia and therapeutic maintenance ofnormothermia are used to protect at-risk brain tissue from secondaryinjury in the setting of anoxic brain injury after cardiac arrest andother central nervous system pathologies. A major limiting factor in theinduction of hypothermia or maintenance of normothermia is thegeneration of shivering, which is a normal adaptive physiologic responsethat serves to bring the body temperature upwards. In addition,shivering in this context can have harmful physiological effects bydiverting energy away from the critical organs such as the brain andheart.

Continuous counterwarming measures (“passive”) counterwarming) have beenfound to have some degree of efficacy in treating shivering. Whenshivering is observed by attending medical personnel, an assessment ismade by the personnel and, if judged to be indicated, a counterwarmingtherapy may be employed, for example by deploying a warming blanket ontoor beneath the patient. Conventionally, passive counterwarming onceapplied is not adjusted over the therapeutic course.

Other anti-shivering measures in common use include pharmaceuticals;currently available options have limited efficacy and may have seriousadverse effects, and the modes of administration may pose risks to thepatient.

SUMMARY

In general the invention provides systems to quantify repetitivemovements of a subject, and particularly to quantify shivering in asubject in the course of therapeutic temperature regulation and to applycounterwarming in a suitable regime for inhibition of shivering. Thecounterwarming regime can operate in a feedback system. In a therapeutictemperature regulation context, where core cooling is being applied tothe patient for maintenance of normothermia or for induction ofhypothermia, the system for shivering quantification and activecounterwarming can be interfaced with the core cooling system. Thecounterwarming regime can be responsive to the quantified shivering, orto the core temperature of the patient, or to the amount of core coolingbeing applied, or to any combination of these factors.

In one general aspect the invention features a method for quantifyingshivering in a subject, by obtaining a signal from a muscle mass that issusceptible to shivering; and quantifying shivering by analysis of thesignal. In some embodiments obtaining the signal includes directlydetecting movement using a periodic motion (vibration) detector such asan accelerometer; in some embodiments obtaining the signal includesobtaining an electrical signal from one or more electrodes, which mayinclude an EMG signal or an ECG+EMG signal. In some embodimentsobtaining the signal includes obtaining both directly detectingvibration of the muscle mass and detecting an electric signal from themuscle mass; in such embodiments the results of quantification ofshivering from the two approaches can be combined. In some embodimentsquantifying shivering includes performing a wave analysis such as aspectral density analysis on the signal; and quantifying shivering fromthe results of the spectral density analysis. In some such embodimentsthe spectral analysis yields a power spectrum. In some embodiments thewave analysis includes a Fourier analysis, such as for example a fastFourier transform. In some embodiments the wave analysis includes anautocorrelation function followed by a Fourier analysis. At least someof the data and signal processing manipulations are carried out using amachine such as a microprocessor programmed to carry out the particularmanipulations.

In some embodiments obtaining the signal includes detecting a combinedECG and EMG signal from the body surface overlying the muscle mass thatis susceptible to shivering and processing the signal to remove the ECGcomponent, resulting in the EMG signal component. In some suchembodiments detecting the combined ECG+EMG signal includes applying anynumber of electrodes at one or more sites on or in the skin overlyingthe muscle mass, or in the muscle mass itself. In other embodimentsobtaining the signal includes detecting a combined ECG and EMG signal,digitizing the combined signal, and performing a wave analysis such as aspectral density analysis on the combined signal; in some embodimentsthe wave analysis is carried out on a frequency range of the spectrumthat is known to correspond to a shivering EMG. In some embodiments themethod further includes obtaining a signal prior to initiating a coolingtreatment (a “baseline” signal), and processing the baseline signal byspectral analysis; then obtaining a signal during cooling (whenshivering may be expected to occur), and processing the shivering signalby spectral analysis; then subtracting one signal from the other toobtain a spectrum that represents only the shivering component.

In some embodiments processing the combined signal includes digitizingthe combined signal. In some embodiments the data separation is carriedout on a set of traces, each of which may include a complete cardiaccycle. The EMG data can be separated from the combined ECG+EMG data byaligning the traces based on an easily identified feature of the ECGwaveform such as the peak of the QRS complex of the ECG and signalaveraging the digitized traces to isolate EMG-free ECG data, andsubtracting the ECG data from the combined EMG and ECG data to yieldECG-free shivering EMG data. Where the data separation is carried out ona set of traces, the signals can be aligned and the separation can becarried out on selected segments of ECG tracings after alignment so thatregions with minimal ECG data elements, such as for example the S-Tsegment and the region between the end of the T wave and the start ofthe P wave, are selectively analyzed. In some embodiments atypical ECGmorphologies are detected, and cardiac cycles that include outliers areidentified and removed from the analysis. In some embodiments atypicalECG morphologies are excluded from analysis by subtracting storedaveraged ECG traces from the same patient under non-shiveringconditions, with exclusion of traces that lead to significant residualECG data (for example, residual voltage amplitude above an adjustablethreshold or residual power spectral density in a frequency range loweror higher than that typically associated with shivering energy).

In some embodiments performing a wave analysis includes carrying out anaveraged fast Fourier transform (“FFT”) analysis. The averaged FFTanalysis may be carried out by performing an FFT on each shivering EMGtracing followed by averaging the FFT spectra to yield an averaged FFTspectrum. In some embodiments, an autocorrelation function is performedon each shivering EMG trace to augment analysis of the rhythmicshivering activity, and then a Fourier analysis is performed on theresults of the autocorrelation.

The intensity of shivering may be quantified by determining theamplitude of the peak spectral power (e.g., the peak Fourier spectrumpower) within an appropriate frequency range that is typical forshivering EMG; or, the shivering may be quantified by determining thearea under the curve of the spectral power within an appropriatefrequency range that is typical for shivering EMG; or, the shivering maybe quantified by analyzing appearances of different peaks correspondingto different frequencies of shivering that occur as shivering becomesmore intense; or, the shivering may be quantified by analyzing change ofspectral peaks or patterns as a function of time.

In some embodiments the measured shivering intensity may be used togenerate a continuous scale or score variable as a function of time thatrepresents shivering intensity. The resulting shivering intensity scaleor score can be used as a means to influence other variables undercontrol in temperature regulation; and/or, the shivering intensity scaleor score can be displayed numerically or graphically for use by aclinician; and/or the shivering intensity scale can be transmitted toanother device for use in another or an additional control process.

In another general aspect the invention features apparatus forquantifying shivering in a subject, by methods described above. Theapparatus includes means for obtaining a signal from a muscle mass thatis susceptible to shivering; and means for analyzing the signal. Themeans for obtaining a signal may include a direct motion detector, suchas an accelerometer and leads from the detector to a signal processor;or an indirect motion detector, such as one or more electrodes adaptedfor placement in or on a surface of the body of the patient, and leadsfor electrical connection of the electrodes to a signal processor. Wherethe detector includes electrodes, the electrodes may include ECGelectrodes or EMG electrodes, such as surface electrodes or needleelectrodes. The means for analyzing the signal includes a signalprocessor adapted to receive signals from the means for obtaining thesignal from the muscle mass, and configured to carry out any of thevarious data processing procedures outlined above, such as amicroprocessor programmed to carry out the particular manipulations.

In another general aspect the invention features a method for applyingactive counterwarming to a patient, by quantifying shivering as outlinedabove, and regulating counterwarming dynamically in response to thequantified shivering or the patient's core temperature, or in responseboth to the quantified shivering or the patient's core temperature.

In another general aspect the invention features a method for applyingactive counterwarming to a patient during therapeutic temperatureregulation of the patient. In some such embodiments the therapeutictemperature regulation includes cooling to reduce the core temperature.In some embodiments applying counterwarming includes applying warming toselected sites on the patient's body; the sites may be body areas notused for cooling the core, including for example hands, feet, or ears,or upper back, or posterior neck, or other sites, or a combination ofthese.

In some embodiments regulating the counterwarming includes adjusting theapplied warming in relation to the intensity of shivering at a moment,or in relation to the patient's core temperature, or in relation to theintensity of core cooling, or in relation to any two or more of these.In some embodiments regulating the counterwarming includes adjusting theapplied warming in relation to any of these or any combination of these,together with one or more of added constants, proportionalitycoefficients, or any mathematical manipulations or interactions of thesevariables.

In some embodiments regulating the counterwarming includes adjusting theapplied warming in relation to the rate of any of or any combination of:change in cooling temperature per unit time, change in shiveringintensity per unit time, or change in patient temperature per unit time;or any mathematical manipulations or interactions of these variables,such as for example a change in the square of any variable per unit timeor the rate of change of any variable per unit time squared.

In some embodiments applying counterwarming includes any of: changingthe temperature of warming applied to all treated body regions; changingthe temperature of warming applied to specific treated body regions;changing the pattern of warming applied to selected treated bodyregions, for example by applying warming to different body regions atdifferent times according to any number of patterns; applying warming ina successive fashion to sequential body regions, for example by warmingthe ears, then warming ears and hands, then warming the ears, hands andfeet; applying selective warming to smaller regions, for example tofingers or toes; or applying warming to other body areas altogether; andwarming various body regions in various patterns, including varying theintensity of warmth applied to different regions, and including therebycreating gradients of warmth.

In some embodiments regulating the counterwarming includes adjusting theapplied warming in relation to any of one or more computer learningalgorithms to determine over time the optimal means of shiveringtreatment in an individual patient.

In another general aspect the invention features apparatus for applyingactive counterwarming to a patient, including apparatus for quantifyingshivering in a subject, as described above, and apparatus for warmingselected areas of the patient's body.

In another general aspect the invention features apparatus for applyingactive counterwarming to a patient during therapeutic temperatureregulation of the patient, including apparatus for quantifying shiveringin a subject, as described above, and apparatus for warming selectedareas of the patient's body; and further including apparatus for coolingthe patient to lower the core temperature.

In some embodiments the apparatus for cooling the patient includes atemperature set point feedback device operatively connected to coolingapparatus; and a core temperature sensor operatively connected to thetemperature set point feedback device. In some embodiments the coolingapparatus includes a cooling blanket, or cooling pads, or anendovascular cooling catheter.

In some embodiments the apparatus for warming selected areas of the bodyincludes counterwarming elements, and a counterwarming controlleroperatively connected to the counterwarming elements and configured andadapted to adjust the warming applied to the counterwarming elements. Insome embodiments the counterwarming controller is operatively connectedto one or a combination of two or more of: a core temperature sensor; acore cooling controller; or the apparatus for quantifying shivering.

In some embodiments the counterwarming elements include heating apparel,including for example heated mittens, heated booties, heated ear muffs,or heated blankets above or below the body; the counterwarming elementscan be heated by any of a variety of means for heat transfer; includingin some embodiments circulating warm water (or other liquid), orinsulated electrical heating coils. In some embodiments thecounterwarming elements include apparatus configured for infusion of asuitable warm sterile liquid (for example, an aqueous or oil-basedliquid) into the external auditory canals of both ears of the patient;such apparatus can include, for example, tubes (inflow and outflow)mounted through plastic earplugs.

Any of the various operative connections by which signals are sent andreceived by any of the various components in any of the embodiments maybe wired or wireless. In particular treatment environments (for example,the intensive care unit) signal transfer by wireless transmitter andreceiver pairs, using a wireless communications protocol such as“Bluetooth”, may be preferred.

Further in general the invention provides systems for isolating a signalof interest from a combined signal containing superimposed first andsecond signals. The first signal is the signal of interest, and may haveany of a variety of properties; the second signal includes recurringepochs or cycles of a stereotyped waveform, and may in addition have arelationship to an external event, such as an external trigger.

Accordingly, in one general aspect, the invention features isolation ofa first signal from a combined (“A+B”) signal containing first (“A”) andsecond (“B”) signals, wherein the second signal includes recurringepochs of a stereotyped waveform, by: digitally sampling the combined(A+B) signal at a suitable sample rate; storing a number (n) of epochsof the combined (A+B) signal; averaging the stored epochs of thecombined signal to obtain an average of the (n) recurring epochs of thestereotyped waveform; and subtracting the average recurring epoch fromeach of at least a subset of the (n) epochs of the combined (A+B) signaland storing the results, containing isolated first (A) signal epochssubstantially free of signal (B) features. At least some of the data andsignal processing manipulations are carried out using a machine such asa microprocessor programmed to carry out the particular manipulations.

In some embodiments the initial sample of each combined (A+B) signalepoch is determined by identifying one or more characteristic featuresof B signal and using the identified feature to index the initial sampleof each epoch. In some embodiments the B signal has a characteristicpeak, and in such embodiments a thresholding technique can be used toidentify the peak and to use a feature (e.g., the apex) of the peak asan initial sample of an epoch. In some embodiments the B signal has atemporal relationship to an external event, and an occurrence of theexternal event can be used to index the start of an epoch. In someembodiments each epoch begins at the indexed first sample and ends atthe sample immediately preceding the first sample of the subsequentepoch (a “complete” epoch); in other embodiments the epochs may betruncated.

In averaging the stored combined (A+B) epochs, a sufficient number ofepochs are averaged to provide an average signal B substantially free ofsignal A, that is, to reduce the contribution of signal A so that theaverage signal B is substantially uncontaminated by signal A components.

The stored isolated signal A epochs may thereafter be subjected toanalysis, for example including performing a wave analysis such as aspectral density analysis on the signal. The spectral analysis may yielda power spectrum, for example. The wave analysis may for example includea Fourier analysis, such as for example a fast Fourier transform. Thewave analysis may in some embodiments include an autocorrelationfunction followed by a Fourier analysis.

In embodiments where complete combined (A+B) signal epochs are stored,the isolated signal A epochs can be rejoined end-to-end to reconstructan extended (reconstructed) signal A having a duration longer than theisolated signal A epochs.

Combined signals of any of a variety of types, from any of a variety ofsources, may be treated in this manner.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1A is a block diagram illustrating a conventional approach totherapeutic temperature management and treatment of shivering.

FIG. 1B is a block diagram illustrating a conventional approach totherapeutic temperature management and treatment of shivering.

FIG. 2A is a block diagram illustrating an approach to therapeutictemperature management according to an embodiment of the invention.

FIG. 2B is a block diagram illustrating an approach to therapeutictemperature management according to another embodiment of the invention.

FIG. 2C is a block diagram illustrating an approach to therapeutictemperature management according to another embodiment of the invention.

FIG. 2D is a block diagram illustrating an approach to therapeutictemperature management according to another embodiment of the invention.

FIGS. 3 and 4 are diagrammatic sketches showing deployment oftemperature management apparatus according to an embodiment of theinvention.

FIGS. 5A and 5B are idealized graphical representations illustrating arelationship over time between cooling bath temperature (FIG. 5A) andwarming element temperature (FIG. 5B).

FIGS. 6A, 6B and 6C are idealized graphical representations illustratingan effect of shivering (FIG. 6B) on a relationship over time betweencooling bath temperature (FIG. 6A) and warming element temperature (FIG.6C).

FIGS. 7A, 7B and 7C are idealized graphical representations showingselection of time windows in an ECG for shivering quantificationaccording to an embodiment of the invention.

FIGS. 8A, 8B, 8C and 8D are idealized graphical representationsillustrating stages in a method for shivering quantification accordingto an embodiment of the invention.

FIGS. 9A, 9B, 9C, 9D, 9E, 9F and 9G are plots of data, detected in ashivering subject using surface electrodes and analyzed according to anaspect of the invention.

FIGS. 10A, 10B, 10C, 10D, 10E, 10F and 10G are plots of data, detectedin a non-shivering subject using an electrode and analyzed according toan aspect of the invention.

FIG. 11A shows a plot of data detected in a shivering subject using anaccelerometer.

FIG. 11B shows a plot of data detected in a subject as in FIG. 11A,showing reduction of shivering by applied counterwarming.

FIG. 11C shows the result of analysis of data as in FIG. 11A accordingto an embodiment of the invention.

FIG. 11D shows the result of analysis of data as in FIG. 11B accordingto an embodiment of the invention.

FIG. 12 is a flowchart showing stages in a shivering quantificationprocess employing electrode detection according to an embodiment of theinvention.

FIG. 13 is a flowchart showing stages in a shivering quantificationprocess employing accelerometer detection according to an embodiment ofthe invention.

FIGS. 14 and 15 are plots of data, detected in a shivering subject usingsurface electrodes and analyzed according to another aspect of theinvention.

FIGS. 16A, 16B, 16C and 16D are graphical representations illustratingstages in a method for identifying outlier waveforms according to anembodiment of the invention.

FIGS. 17A, 17B and 17C are graphical representations illustrating stagesin a method for identifying outlier waveforms according to anotherembodiment of the invention.

DETAILED DESCRIPTION

The invention will now be described in further detail by reference tothe drawings, which illustrate alternative embodiments of the invention.The drawings are diagrammatic, showing features of the invention andtheir relation to other features and structures, and are not made toscale. For improved clarity of presentation, in the FIGs. illustratingembodiments of the invention, features corresponding to features shownin other drawings are not all particularly renumbered, although they areall readily identifiable in all the FIGs.

Referring to FIG. 1A, there is shown generally at 10 a conventionalapproach to therapeutic temperature management in a patient requiringmaintenance of normothermia or induction of hypothermia. According to aconventional approach, a temperature sensor senses the patient's coretemperature. A cooling device, such as cooling pads or an endovascularcooling device, effects a lowering of the core temperature. Therapeuticcooling of the patient may be controlled by a feedback system, in whichthe temperature sensor is operatively connected to a temperature setpoint feedback device and the temperature set point feedback device isoperatively connected to the cooling device. As the patient's coretemperature, sensed by the temperature sensor, falls below a selectedset point, the feedback device signals the cooling device to reducecooling; as the temperature at the probe rises above the set point, thefeedback device signals the cooling device to increase cooling. That is,deviations of the patient's core temperature upward from a desiredtemperature set point trigger cooling of the core, and deviationsdownward from the desired temperature set point trigger reduced coolingor warming of the core. The resulting changes in the patient's coretemperature are sensed at the temperature sensor. When shivering isobserved by attending medical personnel (such as an attending doctor ornurse), an assessment is made by the personnel and, if judged to beindicated, a counterwarming therapy or other anti-shivering measuressuch as medications may be adjusted or initiated.

Such a conventional system is illustrated in further detail generally at100 in FIG. 1B. In this FIG., broken line 101 outlines featuresassociated with the patient, and broken line 111 outlines activitiesassociated with attending medical personnel. A core temperature probe102 is placed at a site on or in the patient's body, to sense thepatient's core temperature. Various temperature probes are characterizedby their placement site, and typical temperature probes include rectal,(urinary) bladder, esophageal, or endovascular probes. A cooling device104 is placed at one or more sites on or in the patent's body, to effecta lowering of the core temperature. Various cooling apparatus are incommon use; particular examples include a cooling delivery apparatus 106that cools a delivery fluid and delivers it to the cooling device 104 byway of a conduit 105. Typical cooling devices include a cooling blanket,or cooling pads, or an endovascular cooling catheter; and typicalcooling delivery apparatus include a cooling fluid reservoir, and afluid pump, by which cooling fluid is circulated from the reservoirthrough the cooling devices and back to the reservoir. Therapeuticcooling of the patient may be controlled by a feedback system, in whichthe temperature probe 102 is operatively connected (103) to atemperature set point feedback device 108 and the temperature setpointfeedback device 108 is operatively connected (107) to the coolingdelivery apparatus 106. Attending medical personnel select systemsettings, such as a target temperature setpoint, using an operatorinterface 109 associated with the temperature setpoint feedback device.As the patient's core temperature, sensed at the probe 102, falls belowthe selected target setpoint, the feedback device 108 signals thecooling apparatus 106, 105, 104) to reduce cooling; as the temperatureat the probe 102 rises above the selected target set point, the feedbackdevice 108 signals the cooling apparatus to increase cooling. That is,deviations of the patient's core temperature upward from a selectedtemperature set point trigger cooling of the core, and deviationsdownward from the selected temperature set point trigger reduced coolingor warming of the core. The resulting changes in the patient's coretemperature are sensed at the temperature probe 102.

To induce normothermia in a patient having an elevated core temperature(fever), the set point at the temperature feedback device may be set towithin the normal body temperature of the patient (about 37° C. for ahuman). To induce hypothermia in a patient in need of hypothermiatreatment, the set point at the temperature feedback device may be setto a temperature below the patient's normal body temperature (for mildhypothermia, for example, to a temperature in a range about 32° C. toabout 34° C. for a human).

As the core is cooled, a shivering response 112 may set in. For humans,shivering may be initiated as the core temperature falls, and mayintensify during active induction of hypothermia. Shivering may be mostintense during maintenance of normothermia in a patient who is trying tomount a fever. Shivering interferes with the therapeutic coolingprocess. In a conventional approach, shivering is controlled byadministration of anti-shivering medications, and typicallyadministration of the medication is initiated before cooling has begun,or before the core temperature has been cooled to a point at whichshivering would be expected. The anti-shivering medication is deliveredto the patient through a conduit 115 from a medication deliveryapparatus 116, which is operable by attending medical personnel by wayof an operator interface 119. The medication may be delivered by asyringe-and-needle device, or a syringe-and-vascular intubation, forexample.

Typically in a conventional approach, the effectiveness of theanti-shivering medication is monitored by direct observation (113) ofthe patient and assessment 114 by attending medical personnel 111. Whenshivering 112 is observed (113), an adjustment 118 in the anti-shiveringmedication may be ordered, to attempt to reduce the shivering.Additional adjustment may be made following further observation andassessment.

FIG. 2A illustrates generally at 200 a therapeutic temperaturemanagement system according to an embodiment of the invention, in whicha counterwarming system quantifies shivering, and counterwarming iseffectuated accordingly. In this embodiment therapeutic cooling iscontrolled by a feedback system, generally as described above withreference to FIG. 1B; but here shivering control differs from that inthe conventional approach.

In FIG. 2A, broken line 201 outlines features associated with thepatient, and broken line 211 outlines activities associated withattending medical personnel.

The therapeutic cooling system in this embodiment is substantiallysimilar to that employed in a conventional treatment approach. A coretemperature probe 202 is placed at a site on or in the patient's body,to sense the patient's core temperature, and a cooling device 204 isplaced at one or more sites on or in the patent's body, to effect alowering of the core temperature. Various temperature probes arecharacterized by their placement site, and typical temperature probesinclude rectal, (urinary) bladder, esophageal, or endovascular probes.Various cooling apparatus are in common use; particular examples includea cooling delivery apparatus 206 that cools a delivery fluid anddelivers it to the cooling device 204 by way of a conduit 205. Typicalcooling devices include a cooling blanket, or cooling pads, or anendovascular cooling catheter; and typical cooling delivery apparatusinclude a cooling fluid reservoir, and a fluid pump, by which coolingfluid is circulated from the reservoir through the cooling devices andback to the reservoir. Therapeutic cooling of the patient may becontrolled by a feedback system, in which the temperature probe 202 isoperatively connected (203) to a temperature set point feedback device208 and the temperature setpoint feedback device 208 is operativelyconnected (207) to the cooling delivery apparatus 206. Attending medicalpersonnel 211 select system settings, such as a target temperaturesetpoint, using an operator interface 209 associated with thetemperature setpoint feedback device. As the patient's core temperature,sensed at the probe 202, falls below the selected target setpoint, thefeedback device 208 signals the cooling apparatus 206, 205, 204) toreduce cooling; as the temperature at the probe 202 rises above theselected target set point, the feedback device 208 signals the coolingapparatus to increase cooling. That is, deviations of the patient's coretemperature upward from a selected temperature set point trigger coolingof the core, and deviations downward from the selected temperature setpoint trigger reduced cooling or warming of the core. The resultingchanges in the patient's core temperature are sensed at the temperatureprobe 202.

To induce normothermia in a patient having an elevated core temperature(fever), the set point at the temperature feedback device may be set towithin the normal body temperature of the patient (about 37° C. for ahuman). To induce hypothermia in a patient in need of hypothermiatreatment, the set point at the temperature feedback device may be setto a temperature below the patient's normal body temperature (for mildhypothermia, for example, to a temperature in a range about 32° C. toabout 34° C. for a human).

As the core is cooled, a shivering response may set in. For humans,shivering may be initiated as the core temperature falls, and mayintensify during active induction of hypothermia. Shivering may occurduring maintenance of normothermia in a patient who is trying to mount afever. According to embodiments of the invention, one or more shiveringsensor elements (motion detectors) 212 are placed at sites overlying amuscle mass that is susceptible to shivering. The motion detectorelement(s) may sense movement of the muscles mass directly; they may forexample include an accelerometer or other movement or vibrationdetection system. Or, the motion detector element may detect the motionindirectly; it may for example include one or more electrodes such as,for example, surface electrodes, subcutaneous electrodes, orintramuscular electrodes; and the shivering sensor elements may includefor example any of a variety of electrodes which measure electricalactivity in the muscle mass, such as electrodes that may be employed forrecording ECG/EMG or EMG.

Where direct sensing of movement of the muscle mass is desired, suitabledetector include any of various vibration monitors, and the detector maybe selected according t its known performance parameters (such as forexample sensitivity, amplitude, frequency range). These may measuredisplacement, velocity, and/or acceleration. Suitable sensors include,for example, piezoelectric displacement transducers (doubly integratedaccelerometers), electromagnetic velocity sensors, piezoelectricvelocity sensors (internally integrated accelerometers), andpiezoelectric accelerometers. Piezoelectric sensors may be useful, andpiezoelectric accelerometers may be particularly suitable. The sensormay include a microelectromechanical system (MEMS) device, for example;and may be sensitive to acceleration in one, or two (2D), or threedimensions (3D). Suitable motion sensors are available from, forexample, Cole-Parmer, Vernon, Ill. 60061 USA; and for example, a smallformat accelerometer such as a “9000 Series Accelerometer”, marketed byVibra-Metrics, Princeton Jct., NJ 08550, USA, may be suitable. Themotion detector (for example, accelerometer) can be held in place on thepatient's skin by, for example, an elastic strap, or an adhesive, suchas a hydrogel adhesive.

Where it is desired to measure movement of the muscle mass indirectly,by electrodes, any of a broad choice of commercially available ECG orEMG electrodes may be used, for example disposable or reusable adhesiveor adherent ECG or EMG or disc-type electrodes or needle monopolar orbipolar EMG electrodes.

A shivering quantification device 218 is operatively connected (213) tothe motion detector 212. The shivering quantification device includes acomputer configured to process and store data corresponding toelectrical signals received from the motion detector, and to generateshivering quantification output, for example as described more fullybelow. Attending medical personnel select shivering quantificationsystem settings using an operator interface 219 associated with theshivering quantification device 218. In this embodiment, the operatorinterface 219 may provide an output to the attending personnel of theresult of shivering quantification; the output may include a visualdisplay, or a sound, for example. Preferably the output is a real-timeor near real-time representation of the condition of shivering in thepatient, for example in graphical and/or numerical form. In embodimentsin which mechanical and electrical shivering detection are bothemployed, the data from the two types of detection system may beintegrated or used in several ways. For example, the average of the twosignals may be displayed or used, or change in measurements from onemethod can be used to validate changes in the other. Discrepanciesbetween the two signals, for example a difference in values between thetwo systems by a preset or user-adjustable difference or a loss ofcorrelation between the trend in the two signals, can triggerre-analysis or notification of the attending medical personnel 211 byway of the operator interface 219.

As noted above, shivering interferes with the therapeutic coolingprocess, and is potentially deleterious to the patient. Reduction ofshivering can significantly improve therapeutic induction of hypothermiaor maintenance of normothermia. Shivering may be controlled byapplication of, or by activation or adjustment of, one or morecounterwarming elements, or by administration of an anti-shiveringmedication.

In the example illustrated in FIG. 2A, one or more counterwarmingelements 214 are placed on exposed areas of the patient's body. Suitableareas for the counterwarming elements include the hands, the feet, andthe ears, for example, or other areas that are not in use for corewarming. Optionally, one or more warming blankets may be placed above,or below, or above and below the patient's body, in contact with skinareas not actively being cooled. The counterwarming elements 214 heatthe areas of the body that they contact, resulting in an inhibition ofshivering. The counterwarming elements may be heating pads or heatingblankets, which may be activated by an electrical current in resistiveconductors, or by a flow of fluid in tubing, for example. Acounterwarming control and delivery apparatus 216 is operativelyconnected (215) to activate the counterwarming elements 214.

Attending medical personnel, alerted to a shivering condition by theoutput from the shivering quantification device, can in responsemanually effect or modify counterwarming (211) by increasing ordecreasing warming by the counterwarming element 214, for example byadjustment or activation (217) of the counterwarming control anddelivery apparatus 216. Changes in the degree of shivering result fromchanges in the core temperature or from changes effected by thecounterwarming element 214. If the counterwarming is effective to reduceshivering, a reduction in shivering is provided to attending personnelas an output of the real-time or near real-time shiveringquantification; if the counterwarming is insufficient to reduceshivering, attending personnel may make further adjustments, until theshivering quantification output indicates that shivering has subsided toan acceptable level.

In some embodiments of a temperature management system, as shown forexample generally at 240 in FIG. 2B, shivering in the patient iscontrolled by a feedback system. In FIG. 2B, broken line 201 outlinesfeatures associated with the patient, and broken line 211 outlinesactivities associated with attending medical personnel. The therapeuticcooling system in this embodiment is substantially similar to thatdescribed with reference to FIG. 2A. In this embodiment, control ofcounterwarming is automated. Here, as in the example of FIG. 2A,shivering sensor elements (motion detectors) 222 are placed at sites onor in the patient's body selected as suitable for detection ofshivering, usually at muscle masses that are susceptible to shivering.The motion detector may include one or more electrodes; or, the motiondetector may include one or more vibration detection sensors (forexample, accelerometers), or the motion detector may include bothelectrodes and vibration detection sensors. A shivering quantificationdevice 228 is operatively connected (223) to the motion detector 222.The shivering quantification device includes a computer configured toprocess and store data corresponding to electrical signals received fromthe motion detector, and to generate shivering quantification output,for example as described more fully below. Attending medical personnelselect shivering quantification system settings using an operatorinterface 229 associated with the shivering quantification device 228.Also in the example illustrated in FIG. 2B, one or more counterwarmingelements 224 are placed on exposed areas of the patient's body,generally as described above with reference to FIG. 2A. A counterwarmingcontrol and delivery apparatus 226 is operatively connected (225) toactivate the counterwarming elements 224.

In this embodiment, as in the example of FIG. 2A, attending medicalpersonnel select shivering quantification system settings using anoperator interface 229 associated with the shivering quantificationdevice 228. The operator interface 229 may provide an output to theattending personnel of the result of shivering quantification; theoutput may include a visual display, or a sound, for example. Preferablythe output is a real-time or near real-time representation of thecondition of shivering in the patient. Additionally, in this embodiment,the shivering quantification device 228 provides (227) an output to thecounterwarming control and delivery apparatus 226. The counterwarmingcontrol and delivery apparatus 226 includes a computer configured toprocess and store data corresponding to electrical signals received fromthe shivering quantification device 228, and to generate counterwarminginstructional output (227) to the counterwarming control and deliveryapparatus 226, for example as described more fully below. This output iscorrelated to the degree of shivering. The counterwarming control anddelivery apparatus 226 can in response to the output signal (227) fromthe shivering quantification device 228 automatically effect or modifycounterwarming by increasing or decreasing warming by the counterwarmingelement 224. Changes in the degree of shivering result from changes inthe core temperature or from changes effected by the counterwarmingelement 224. If the counterwarming is effective to reduce shivering, areduction in shivering is sent to the counterwarming control anddelivery apparatus 226 as an output of the real-time or near real-timeshivering quantification by the shivering quantification system (222,223, 228), and the counterwarming is automatically adjusted accordingly;if the counterwarming is insufficient to reduce shivering, a lack ofreduction in shivering is signaled by the shivering quantificationsystem (222, 223, 228) to the counterwarming control and deliveryapparatus 226, which may automatically make further adjustments, untilthe shivering quantification output indicates that shivering hassubsided to an acceptable level.

A more complex therapeutic temperature management system according to anembodiment of the invention is shown generally at 20 in FIG. 2C. In thisembodiment, as in the example of FIG. 2B, both therapeutic cooling andcounterwarming are controlled by feedback, and here additional feedbackloops are optionally available. In such embodiments, a temperaturesensor senses the patient's core temperature. A cooling device, such ascooling pads or an endovascular cooling device, effects a lowering ofthe core temperature. Therapeutic cooling of the patient may becontrolled by a feedback system, in which the temperature sensor isoperatively connected to a temperature set point feedback device and thetemperature set point feedback device is operatively connected to thecooling device. As the patient's core temperature, sensed by thetemperature sensor, falls below a selected set point, the feedbackdevice signals the cooling device to reduce cooling; as the temperatureat the probe rises above the set point, the feedback device signals thecooling device to increase cooling. That is, deviations of the patient'score temperature upward from a desired temperature set point triggercooling of the core, and deviations downward from the desiredtemperature set point trigger reduced cooling or warming of the core.The resulting changes in the patient's core temperature are sensed atthe temperature sensor. A detector at the patient sends a signal to ashivering sensor system, which processes the signal and sends acounterwarming instruction signal to a counterwarming control device.The counterwarming control device in turn sends a signal tocounterwarming elements at the patient to initiate or adjust the amountof counterwarming. Effective counterwarming inhibits shivering.

An example of such an embodiment is shown generally at 260 by way ofexample in FIG. 2D, in which broken line 201 outlines featuresassociated with the patient, and broken line 211 outlines activitiesassociated with attending medical personnel. The therapeutic coolingsystem and the counterwarming system in this embodiment aresubstantially similar to those described with reference to FIG. 2B.Particularly, here, as in the example of FIG. 2B, a shivering sensorelement (motion detector) 232 is placed at a site on or in the patient'sbody selected as suitable for detection of shivering, usually at amuscle mass that is susceptible to shivering. The motion detector mayinclude one or more electrodes; or, the motion detector may include oneor more vibration sensors (for example, an accelerometer). A shiveringquantification device 238 is operatively connected (233) to the motiondetector 232. The shivering quantification device includes a computerconfigured to process and store data corresponding to electrical signalsreceived from the motion detector, and to generate shiveringquantification output, for example as described more fully below.Attending medical personnel select shivering quantification systemsettings using an operator interface 239 associated with the shiveringquantification device 228. Also in the example illustrated in FIG. 2D,one or more counterwarming elements 234 are placed on exposed areas ofthe patient's body, generally as described above with reference to FIG.2B. A counterwarming control and delivery apparatus 236 is operativelyconnected (235) to activate the counterwarming elements 234.

Additionally, in the example illustrated in FIG. 2D, the counterwarmingcontrol and delivery apparatus 236 is configured to receive signals fromone or more other components of the apparatus; for example: thecounterwarming control and delivery apparatus may be operativelyconnected (242) to receive electrical signals from the core temperaturesensor 202, and/or operatively connected (244) to receive data signalsfrom the temperature setpoint feedback device 208, and/or operativelyconnected 246) to receive data signals from the cooling deliveryapparatus 206.

The three general feedback mechanisms by which the counterwarmingcontrol and delivery apparatus 236 may initiate and/or regulate thedegree or pattern of counterwarming may be used in concert as showndiagrammatically in FIG. 2D; alternatively the feedback mechanisms maybe used in various embodiments alone or in any combination. For example,a counterwarming control and delivery apparatus 236 may be set up torespond solely to the degree of cooling being applied by the coolingdelivery apparatus 206, without regulation by the other feedbackmechanisms. Similarly, any combination of the three feedback mechanismsmay be used alone or in any combination of two or three feedbackmechanisms. In some embodiments, for example, the signals received bythe counterwarming control and delivery apparatus 236 from the coolingdelivery apparatus 206 and the temperature set point feedback device 208by way of their operative connections (246), (244) with thecounterwarming control and delivery apparatus 236 are set up in such away that the counterwarming control and delivery apparatus 236 and thecooling delivery apparatus 206 are part of one unit of operation. Inother embodiments, for example, the counterwarming control and deliveryapparatus 236 is not part of the same unit of operation as the coolingdelivery apparatus 206 but is instead connected by way of operativeconnections (246), (244) to any separate cooling delivery apparatus 206capable of sending digital or analog signals representing patienttemperature and/or extent of core cooling energy being employed to formoperative connections (246), (244) with an external counterwarmingcontrol and delivery apparatus 236 such that these connections may beused to regulate any or all of the functions of the counterwarmingcontrol and delivery apparatus 236 as described herein. In someembodiments, for example, patient temperature data may be acquiredseparately by direct operative connection of a temperature probe to thecounterwarming control and delivery apparatus 236 with or without use ofadditional temperature data from an operatively connected coolingdelivery apparatus 206.

Additionally, the counterwarming control and delivery apparatus 236 mayoptionally be configured to receive input (247) directly from attendingmedical personnel, in the event manual override of input to thecounterwarming control by the shivering quantification device isindicated or desired. Manual override may be indicated where, forexample, under particular circumstances, combined ECG+EMG data may bedifficult to process; or where, for example, the shiveringquantification appears to attending personnel to be spurious. In such asituation the attending personnel may wish to manually enter a degree ofshivering, based on a clinical scale, which may be a standardizedclinical scale. (See, e.g., Stroke, Vol. 39(12) pages 3242-47, December2008, EPub Oct. 16, 2008). Where manual override of the shiveringquantification is employed, feedback based on cooling intensity or coretemperature may still be employed automatically by the counterwarmingcontroller at the discretion of the attending medical personnel 211 byway of the operator interface 239. Manual override by way of theoperator interface 239 or automatic override by feedback mechanism canbe triggered when prolonged higher intensity counterwarming has beenapplied, in order to prevent the possibility of thermal injury.

According to various embodiments of the invention the shivering controlsystem can regulate the intensity, the timing and/or the pattern ofapplication of counterwarming in a dynamic fashion based on data relatedto the intensity of core cooling, or measured shivering, or patient coretemperature, or to any combination of any two or more of these factors.

Embodiments of a system according to the invention are illustrateddiagrammatically generally at 30 and 40 in FIGS. 3 and 4, as applied toa patient 16 in need of normothermia maintenance or induced hypothermia.Typically the patient is in a supine position. In these embodiments anintegrated control device (a suitably configured computer) 12 isoperatively connected to cooling pads 18, counterwarming elements 20,and shivering sensor elements 22, which are placed on suitable sites onthe patient's body. Additionally, a core temperature probe (not shown inthe FIGs.) is connected to the integrated control device 12. Optionally,a warming blanket 24 may be placed over and/or under the patient, asshown in FIG. 4.

The integrated control device 12 is configured and programmed to receiveand/or send electrical signals from/to the respective sensors, elements,probe and pads on and in the patient's body. For example, the integratedcontrol device may receive electrical signals from the shivering sensorelements and the core temperature probe; and, for example it may sendelectrical instruction signals to the cooling pads and counterwarmingelements. The integrated control device 12 may include variouscomponents, including one or more microprocessors and memory devices,that receive and process various received signals. Various components ofthe integrated control device 12 may be configured to communicateelectrically with one another and to process received signals. Forexample, a counterwarming controller component may be configured toreceive and process electrical signals from a temperature set pointcontroller component. All the data and signal processing functions maybe carried out in the integrated control device, as suggested by theFIGs.; optionally, at least a portion of the data processing or signalprocessing functions may be carried out in hardware (microprocessorand/or memory) situated on or in one or more of the sensor elements.

The active counterwarming elements are used to warm various body regionssuch as the hands, feet, ears, upper back, posterior neck, or otherexposed regions not being used as a site for core cooling. Hand warmingelements may be in a glove form that encloses each of the fingersseparately, in a mitten form that encloses four fingers together, or ina form of a wrap around the hand. Variations of the shape of the handwarming elements may be used to allow for appropriate access to sitesfrequently used in critical care, such as for example the region of theradial artery in the wrist. Foot warming elements may be applied to thefeet selectively (similar in shape to shoes) or to the feet and anklestogether (similar in shape to socks). Ear warming elements may take aform similar to earmuffs, or may take the form of a small warmingblanket applied to the ears and neck area, for example. Other areas arewarmed by warming blankets or small pads that are selectively applied orcover a larger area of the patient's body or are placed under thepatient.

Placement and analysis of the shivering sensor elements is customized tothe needs of the particular application.

Generally, as illustrated diagrammatically in FIGS. 5A and 5B, thecounterwarming element temperature is regulated roughly in proportion tothe inverse of the cooling element temperature as measured, for example,at the bath of cooling liquid flowing to the patient cooling elements.That is, as the cooling element (cooling bath) temperature falls, afeedback loop causes the counterwarming temperature to rise.

As illustrated diagrammatically in FIGS. 6A, 6B and 6C, the warmingelement temperature (FIG. 6C) can according to the invention be adjustedupward during periods of shivering (FIG. 6B). FIG. 6A shows measuredchanges in the cooling bath temperature. FIG. 6B shows a sample plot ofshivering over the same time period, quantified in this exampleaccording to the invention at three score levels: a level 0corresponding to no shivering or shivering less than a threshold level;a level 1 corresponding to mild shivering; and a level 2 correspondingto vigorous shivering. In other embodiments, shivering intensity may beencoded as a continuous variable or as a score variable with morelevels. FIG. 6C shows counterwarming element temperature over the sametime period. As noted above, in the absence of regulation thecounterwarming element temperature generally mirrors the cooling bathtemperature. The broken line 62 shows how counterwarming elementtemperature unregulated by shivering would appear, generally mirroringthe plot of cooling bath temperature in FIG. 6A. The plot 64 shows aregulated counterwarming temperature, in which the warming is adjustedupward during periods of shivering. The regulated counterwarming elementtemperature over the same time period is adjusted upward during level 1shivering, adjusted further upward during level 2 shivering, adjusteddownward during a subsequent period of reduced (level 1) shivering, andadjusted further downward (mirroring the cooling bath temperature plot)during a subsequent period of level 0 (no or undetected) shivering.Particularly, for example, the counterwarming temperature would in theabsence of shivering-based regulation have returned to off or to abaseline level during the interval indicated by the bracket labeled 2;instead, because maximum shivering is detected during this interval, theadjusted counterwarming temperature remains high, as indicated by thedouble arrow at 66.

Quantification of shivering according to various embodiments of theinvention may include some or all of the following stages andcomponents.

For electrode-based detection, two or more electrodes may be arrayed toobtain the surface EMG data. In some applications the shivering sensorelements may include surface electrodes, such as for example ECG or EMGelectrodes; and they may be applied to any exposed skin region overlyinga muscle group engaged in shivering. Or, in some applications, needleEMG electrodes may be used instead of surface ECG electrodes to detectshivering at a higher level of sensitivity.

The data processing algorithm to selectively enhance the shivering EMGcomponent of the ECG and EMG data may be set up in a customizablefashion: complete cardiac cycles of ECG data can be analyzed, orspecific segments of ECG tracings can be analyzed after alignment sothat regions having minimal ECG data elements (such as the S-T segmentand the region between the end of the T wave and the start of the Pwave) are selectively analyzed.

As in known ECG measurement using surface electrodes, voltagedifferences from pairs of surface ECG electrodes may be measured bymeans of a standard ECG amplifier with an appropriate reference andground. In a shivering patient, the measured voltage tracing from anypair of ECG surface electrodes overlying muscle groups involved inshivering will be a superimposition of ECG and shivering electromyogram(EMG) tracings. The mixed ECG+EMG tracing may be digitized by standardanalog-to-digital conversion at a sampling rate that adequately recordsthe higher frequency EMG data.

Using standard techniques for automated digital signal detection of thecharacteristic components of the ECG, such as the QRS complex, severalcomplete cardiac cycles of ECG+EMG data may be sampled and stored inseparate digital buffers.

Using standard techniques for automated digital signal detection ofpremature ventricular complex (PVCs) or other examples of atypical QRSmorphology, cardiac cycles that include a QRS morphology that is anoutlier compared to the baseline are identified and omitted from theanalysis. Standard techniques for distinguishing atypical QRS morphologyare known in the prior art and include, for example, detection of QRScomplexes with longer duration than the baseline duration, detection ofQRS complexes with a different electrical vector (the ECG ‘axis’) fromthat of the baseline QRS, and detection of QRS complexes with higheramplitude than that of the baseline ECG.

Any of several techniques may be employed to exclude atypical ECGcomplexes. In some embodiments, in which the desired temporal resolutionfor shivering quantification allows for averaging of a larger number ofcomplexes, the number of averaged complexes may be increased to minimizeor substantially reduce the impact of outlier complexes in the analysis.In such circumstances in which frequent outlier ECG morphologies areidentified by the user or by any of the techniques of analysis describedor referenced herein, the number of averaged tracings may be increased,manually or automatically, to minimize or substantially reduce theimpact of outlier complexes in the analysis.

In some embodiments, a narrow temporal window starting at the peak ofthe QRS complex (for example, as identified by an amplitude trigger) iscaptured. The narrow temporal window of captured data, having a timeduration representing a small percentage of the total ECG cycle, forexample 10 to 50 milliseconds, may be subjected to analysis todiscriminate outlier ECG cycles with atypically wide QRS morphologies.

Outlier ECG waveforms may be identified by detecting QRS complexes thatare atypically broad. For example, FIGS. 16A-16D show stages in such anapproach by measuring the slope of the downward deflection of the QRS.In this approach, analysis of the narrow temporal window including thedownslope of the QRS complex includes identification of outliers bydetermining the slope of the downward deflection of the ECG waveformfrom the peak of the QRS complex to the end of the narrow temporalwindow, such that complexes with a downward slope that is insufficientlysteep are excluded from analysis. As outlier QRS complexes such aspremature ventricular contractions are often of higher amplitude thantypical QRS complexes, in some embodiments the amplitudes of thetracings are normalized to the amplitude of a typical QRS complex priorto analysis of the QRS downslope. FIG. 16A shows two cycles, oneincluding a typical QRS complex 162 and the other including an atypicalQRS complex 164. A narrow temporal window is set beginning at each QRSpeak, as shown at 163 (typical) and 165 (atypical) in FIG. 16B. Theportions of the traces within the temporal windows are selected, asshown in FIG. 16C: the window 163 contains the downward deflection 166of the typical QRS complex, and the window 165 contains the downwarddeflection 168 of the atypical QRS complex. The slopes of the traceportions can be compared, optionally following normalization of theamplitudes of the defined trace portions, as shown at FIG. 16D. The lesssteep slope of the trace portion 168′ by comparison with the slope ofthe typical trace portion 166′ identifies the QRS complex having thepeak 164 as atypical, and the ECG waveform including such an atypicalQRS complex is excluded from subsequent analysis. The cutoff slope forexclusion by this technique may be determined based on establishment ofthe typical ECG downward slope by analysis of average ECG slopes in thepatient being monitored, or by user identification of a typical ECGwaveform for the patient being monitored. In some embodiments, the usercan be presented by means of computer display with a visual array of ECGwaveforms from the patient being monitored so that the user may selectby computer interface one or more typical ECG waveforms from which theappropriate cut point for the downslope of the QRS complex may bedetermined.

And, for example, FIGS. 17A-17C show stages in an approach by measuringthe width of the QRS complexes at the baseline. ECG complexes having abaseline QRS complex width above a specific cutoff are excluded fromsubsequent analysis. FIG. 17A shows two cycles, one including a typicalQRS complex 172 and the other including an atypical QRS complex 174. Thebaseline 170 b of the ECG trace is established, and the temporal limitsof the QRS complexes at the baseline are determined, as shown at FIG.17B. The time limited typical QRS complex is shown at 176 and the timelimited atypical QRS complex is shown at 178. The widths of the QRScomplexes at the baseline are then measured, as shown in FIG. 16C: thewidth of the typical QRS complex 176′ is indicated at 172 w, and thewidth of the atypical QRS complex 178′ is indicated at 174 w. Where aQRS width exceeds a threshold width (as for example width 174 w) the ECGtrace containing the QRS complex having the wider peak is excluded fromsubsequent analysis.

The threshold QRS width for exclusion by this approach may be determinedby establishing the typical QRS width in the particular patient beingmonitored. This may be done by analysis of average QRS widths in thepatient, or by user identification of a typical ECG waveform for thepatient. In some embodiments, the user is presented by means of computerdisplay with a visual array of ECG waveforms from the patient beingmonitored so that the user may select by computer interface one or moretypical ECG waveforms from which the appropriate threshold QRS complexwidth may be determined. The threshold may be set at some limit, such asone or two standard deviations, for example, above a mean typicalwaveform width.

In other embodiments, the analysis of the narrow temporal windowcomprising the downslope of the QRS complex includes identification ofoutliers by analysis in the frequency domain by means, for example, ofFourier analysis, such as a Fast Fourier Transform (FFT), such thattypical narrow complexes are identified as having a high frequency peakand atypical wide complexes lack this high frequency peak. The frequencyand amplitude cut points of the Fourier analysis or other frequencyanalysis used for exclusion of ECG tracings by this method may bedetermined based on establishment of the typical ECG high frequency peakby analysis of average ECG high frequency peaks or by useridentification of a typical ECG waveform. In some embodiments, the useris presented by means of computer display with a visual array of ECGwaveforms from the patient being monitored so that the user may selectby computer interface one or more typical ECG waveforms, from which theappropriate frequency and amplitude cut points of the Fourier analysisor other frequency analysis may be determined to exclude outlier ECGcomplexes.

Additionally, standard techniques may be employed for automated digitalsignal detection of premature ventricular complex (PVCs) or otherexamples of atypical QRS morphology. Cardiac cycles that include a QRSmorphology that is an outlier compared to the baseline may be identifiedby such established techniques and omitted from subsequent analysis.Standard techniques for distinguishing atypical QRS morphology are knownand include, for example, detection of QRS with a different electricalvector (the ECG “axis”) from that of the baseline QRS and detection ofQRS complexes with higher amplitude than that of the baseline ECG.

The data separation can be carried out on a set of traces, each of whichmay include a complete cardiac cycle. The EMG data can be separated fromthe combined ECG+EMG data by aligning the traces based on an easilyidentified feature of the ECG waveform such as the peak of the QRScomplex of the ECG and signal averaging the digitized traces to provideECG data having a reduced contribution of EMG data, and subtracting theECG data from the combined EMG and ECG data to yield shivering EMGtraces having a reduced contribution of ECG data. A sufficient number oftraces are averaged to provide an average EMG signal substantially freeof ECG signal components, that is, to reduce the contribution of ECGsignal components so that the average EMG signal is substantiallyuncontaminated by ECG signal components.

Where the data separation is carried out on a set of traces, the signalscan be aligned and the separation can be carried out on selectedsegments of ECG tracings after alignment so that regions with minimalECG data elements, such as for example the S-T segment and the regionbetween the end of the T wave and the start of the P wave, areselectively analyzed. As described above beginning at paragraph [0091],typical and atypical ECG morphologies can be detected, and cardiaccycles that include outliers (atypical ECG morphologies) can beidentified and removed from the analysis. Atypical ECG morphologies canalso be excluded from analysis by subtracting stored averaged ECG tracesfrom the same patient under non-shivering conditions, with exclusion oftraces that lead to significant residual ECG data (for example, residualvoltage amplitude above an adjustable threshold or residual powerspectral density in a frequency range lower or higher than thattypically associated with shivering energy).

A number (n) of samples of digital ECG+EMG “raw” data (e.g., 10 cardiaccycles) are then automatically aligned in the temporal domain based onthe R wave (the positive peak of the QRS complex of the ECG) or otherECG features, as illustrated for 3 cardiac cycles 34 in FIG. 8A.

Reference is now made to FIG. 8B. The average (“mean of n tracings” 35)of the aligned n ECG+EMG “raw” data samples 34 is stored in a selectedbuffer (the “average ECG buffer”). Averaging removes or greatlyminimizes the “noise” of shivering EMG and preserves the stereotyped ECGwaveform (standard prior art of signal averaging to reduce noise). Thedifference 36 between each of the n ECG+EMG tracings and the average ECGis stored in another series of buffers (“EMG buffers” 1−n). FIGS. 8A and8B may be summarized by: (ECG+EMG 34)−(averaged ECG 35)=(EMG 36)

EMG data obtained in the manner described herein yields an EMG tracingwith a stable baseline that is uncontaminated by the high amplitudeexcursions of the ECG. In some embodiments, EMG tracings with anunstable or undulating baseline produced by the presence of atypical ECGcomplexes in the described averaged signal subtraction process can beidentified and excluded from analysis. Traces with such unstable orundulating baselines can be identified in some embodiments by analysisin the frequency domain by means, for example, of Fourier analysis, suchas a Fast Fourier Transform (“FFT”), to identify the presence, above aprescribed level, of low frequency (for example, less than 4 Hz)contamination.

The process described above for extracting EMG data from thesuperimposed ECG+EMG data can be more generally characterized by theprocess of averaged signal subtraction to largely remove a stereotypedsignal (for example, ECG data) from a second signal that lacks the samestereotyped features (for example, EMG data), by the process ofsubtracting the averaged stereotyped signal after alignment of thesuperimposed tracings using detectable features of the stereotypedsignal. The process of aligning the traces can utilize identifiablefeatures of the stereotyped signal (such as the high amplitude peak ofthe ECG R wave) or can take advantage of time locking of the stereotypedsignal to a measurable event (such as an external stimulus that producesa stereotyped response with a stereotyped time delay) to register thesuperimposed tracings, the processes usually employed in signalaveraging. After alignment of the traces such that averaging the traceslargely removes the second signal, this isolated first signal tracing isused to isolate the second signal from the superimposition of the two bythe process of wave subtraction.

To further minimize contamination of the EMG data stored in the EMGbuffers, the (ECG+EMG) and (averaged ECG) tracings can first be‘clipped’ in the temporal domain such that a segment of data withminimal ECG voltage deflections is chosen prior to subtraction of(ECG+EMG)−(averaged ECG). Examples of such clipping are illustrated inFIGS. 7A, 7B and 7C. FIG. 7A shows a trace over a time domain includingtwo complete cardiac cycles. This signal may be clipped in the timedomain to remove the PQ interval and the QRS complex, leaving the T wavetrace and the interval between the T wave and the following P wave, asshown for example at A in FIG. 7B, for analysis. This trace A may befurther clipped to remove the T wave, leaving only the interval betweenthe T wave and the following P wave, as shown for example at B in FIG.7C, for analysis.

Then a wavelet analysis such as a fast Fourier transform (FFT) may beperformed on each of the 1−n EMG buffers, and the resulting powerspectrum of each FFT may be stored in another series of buffers (“EMGFFT buffers” 1−n), as illustrated at 38 in FIG. 8C. The 1−n EMG FFTbuffers may then be averaged and the result stored in another buffer(“average EMG FFT buffer”), as illustrated in FIG. 8D. In someembodiments, autocorrelation is performed prior to fast Fouriertransform (FFT).

Alternatively, the average spectral power of the shivering EMG may bedetermined by subjecting non-shivering ECG epochs to spectral analysis,and, during monitoring, subjecting shivering ECG cycle epochs(containing ECG and EMG data) to spectral analysis, and then subtractingan average of the non-shivering spectra (ECG only) from an average ofthe shivering spectra (ECG+EMG) to obtain an averaged EMG spectrum.

Particularly according to this approach, ECG tracings are first obtainedfrom a subject during non-shivering conditions, such as for exampleprior to cooling for normothermia or for induced hypothermia. Thenon-shivering ECG is separated into single ECG cycle epochs as describedabove and aligned in the temporal domain on specific ECG features suchas the peak of the QRS complex. These non-shivering ECG epochs are eachsubjected to spectral analysis, for example FFT analysis, and theaverage of n spectral analyses (on n such non-shivering ECG epochs) isthen obtained and stored in a digital buffer. When it is desired tomonitor shivering in the same subject, this process is repeated: ashivering state (ECG+EMG) tracing is obtained, and is separated intosingle ECG cycle epochs as described above and aligned in the temporaldomain on specific ECG features such as the peak of the QRS complex.These shivering state ECG+EMG epochs are each subjected to spectralanalysis, for example FFT analysis, and the average of n spectralanalyses (on n such shivering ECG epochs) is then obtained and stored ina different digital buffer. FIG. 14 shows results of such averagedspectral analyses 144 for nonshivering ECG epochs 144, and for shiveringstate ECG+EMG epochs 142, each epoch corresponding to a cardiac cyclefrom the peak of the QRS to the region of the T wave. The averagespectral analysis (in this example, FFT analysis) from the non-shiveringstate epochs is subtracted from the average spectral analysis (in thisexample, FFT analysis) from the shivering state epochs, substantiallyminimizing the spectral contribution of the average ECG spectral powerand revealing the averaged shivering EMG spectrum, with a peak in theappropriate frequency domain for shivering, as shown in FIG. 15. Theincreased spectral energy around 10 Hz that can be appreciated as aseparation of the two lines 142, 144 in FIG. 14 appears in FIG. 15 as aclear peak 154 in this frequency range. The degree of shivering may bequantified according to the height 156 of the peak 154. A frequencyrange of interest for shivering energy may be isolated, as suggested bythe vertical lines 150 and 150′, defining a region of interest 158 forshivering energy, and the degree of shivering may be quantified by, forexample, the area under the curve 152 in this region, and/or by the peakof the curve 152 in this region.

The average spectral power of the shivering EMG obtained by any methoddescribed above may be used alone or in combination to quantifyshivering intensity. In some embodiments, the same data may be processedin parallel by both methods and the result of both analysis methods maybe used to display or otherwise use a consensus of the two measurementsor to check the validity of measurements obtained by one method againstmeasurements obtained by the other method.

The average spectral power of the EMG data may be used to generate aquantitative or semi-quantitative measure of shivering intensity by, forexample, recording one of the following values:

a. The amplitude of the peak spectral power within an appropriatefrequency range that is typical for shivering EMG.

b. The area under the curve of the spectral power within an appropriatefrequency range that is typical for shivering EMG.

c. Analysis of the appearance of different peaks corresponding todifferent frequencies of shivering that occur as shivering becomes moreintense.

d. Analysis of the change of such spectral peaks or patterns as afunction of time.

The shivering intensity thus measured may be used to generate acontinuous variable or score variable as a function of time thatrepresents shivering intensity. The shivering intensity scale or scoremay be displayed numerically or graphically for clinical use; or, theshivering intensity scale or score can be used as a means to influenceother variables under control in related applications (such as thecontrol of counterwarming in the methods according to embodiments of theinvention).

The gain of the amplification of the ECG+EMG data described above willdetermine whether low amplitude shivering EMG is detected by the aboveprocess, and accordingly amplifier gain may be adjusted as follows:

a. Higher amplifier gain settings can be chosen by the user forapplications in which the user wishes to detect more subtle degrees ofshivering.

b. Amplifier gain settings may be pre-adjusted by the system or the usersuch that prior to application of therapeutic cooling (and thus prior toshivering), the baseline amplifier gain is increased until noise notrelated to shivering is detected and the gain is set to a level justbelow this point.

For the ECG+EMG data analysis system, the user may in some embodimentschoose the best electrode pair(s) to be analyzed by electronic means byway of the operator interface to yield the optimal ECG morphology foranalysis. In some embodiments, the shivering analysis system mayautomatically select the optimal electrode pair(s) for analysis based oncomputerized identification of specific ECG components, for example byselecting the electrode pair with the highest R wave amplitude.

In some embodiments of the direct motion-sensing shivering detectionsystem, an accelerometer or other vibration sensor capable of measuringmovement in three dimensions is used. In these embodiments, the datafrom each of the three planes (x, y, and z) are acquired in digital formfrom the device, and these data can be used in different ways. In someembodiments, the plane with the highest amplitude signal or highestspectral energy in a frequency range associated with shivering may beused for analysis. In other embodiments, the average signal from thethree planes is used for analysis. In other embodiments, the vector ofmaximal shivering movement may be determined from the relative amplitudeof the waveforms from each plane or from the relative spectral energy ina frequency range associated with shivering from each plane, and theshivering waveform for this vector of maximal shivering movement may bereconstructed by appropriate weighted averaging of the waveforms fromthe three planes for use in analysis of shivering. In other embodiments,the determination of the vector of maximal rhythmic movement isdetermined from the relative spectral energy in a frequency rangeassociated with shivering from each plane and this value is tracked overtime to discriminate between non-shivering muscle movements or activity(which have a changing vector of movement) and shivering activity (whichhas a relatively constant vector of movement for a given muscle group).

For detection based on direct sensing of periodic movement (vibration),wavelet analysis (spectral processing) such as fast Fourier transform(FFT) analysis may be carried out directly on the data signal from thesensor. Or in some instances preferably, an autocorrelation step may becarried out prior to performing the wavelet analysis. The peak of theresulting curve, or the area under the curve, or other approach asdescribed for treatment of electrode-derived data, can be used togenerate the shivering quantification signal. As in the treatment ofelectrode-derived data, the frequency range in the vibration-sensorderived data stream can optionally limited to a range appropriate forshivering. A “baseline” pre-shivering data stream can be obtained fromthe vibration-sensor data, as in the electrode data, to minimize (or atleast reduce) contributions of mechanical vibrations not related toshivering. For example wavelet components related to movements orvibrations transmitted mechanically from devices in the treatmentenvironment (for example the ICU) such as pumps or ventilators could beremoved in this way. Non-periodic or less regular vibration contaminantssuch as patient movement, or coughing, or contact with other persons,can be minimized by averaging the vibration FFT over time and by use ofan autocorrelation function prior to each FFT (thereby enhancing theanalysis of rhythmic signals), so that non-periodic and non-continuousdata are eliminated from the analysis.

Example 1

For detection based on electrode-based sensing of electrical activity,one or more electrodes may be placed on or in the body at sitessusceptible to shivering. FIG. 9A is a plot (trace) of a data signalobtained over a duration of several seconds (the ECG epoch), by an ECGelectrode applied to the skin of a shivering subject, at a siteoverlying a muscle mass (the pectoral muscles) that is susceptible toshivering. ECG cycles are clipped from the ECG epoch, and outlier QRScomplexes are rejected. The resulting ECG cycles are aligned on thepositive peak of the QRS complex of each, as shown at 92 in FIG. 9B.Then the aligned ECG cycles are averaged, yielding a result as shown at93 in FIG. 9C. Then the data shown in FIG. 9C are subtracted from thedata for each of the aligned ECG cycles shown in FIG. 9B, to yield aresult as shown at 94 in FIG. 9D. The data of FIG. 9D are then clippedat 95, to remove the initial QRS portion of the traces (indicated byarrow A), and leaving the portion 96 as shown in FIG. 9E (correspondingto arrow B in FIG. 9D, for autocorrelation followed by fast Fouriertransform (FFT). FIG. 9F shows the resulting power spectral density(PSD) curves derived from the data in the traces of FIG. 9E. The PSDsfor the traces are then averaged to yield the average PSD curve as shownin FIG. 9G. The PSD curves (peaks) 98, 99 represent a quantification ofshivering.

FIG. 10A is a plot (trace) of data obtained generally as described withreference to FIG. 9A from a subject who was not shivering; and FIGS.10B-10G illustrate analysis of the data in a manner generally similar tothat described with reference to FIGS. 9A-9G. The data in FIG. 10A wereobtained over a duration of several seconds (the ECG epoch), by an ECGelectrode applied to the skin of a subject who is not shivering, at asite overlying a muscle mass (the pectoral muscles) that is susceptibleto shivering. ECG cycles are clipped from the ECG epoch, and theresulting ECG cycles are aligned on the positive peak of the QRS complexof each, as shown at 192 in FIG. 10B. Then the aligned ECG cycles areaveraged, yielding a result as shown at 193 in FIG. 10C. Then the datashown in FIG. 10C are subtracted from the data for each of the alignedECG cycles shown in FIG. 10B, to yield a result as shown at 194 in FIG.10D. The data of FIG. 10D are then clipped at 195, to remove the initialQRS portion of the traces (indicated by arrow A), and leaving theportion 196 as shown in FIG. 10E, for autocorrelation followed by fastFourier transform (FFT). FIG. 10F shows the resulting power spectraldensity (PSD) curves derived from the data in the traces of FIG. 10E.The PSDs for the traces are then averaged to yield the average PSD curveas shown in FIG. 10G. As the very low PSD curves (peaks) show at 198,199, shivering has been substantially reduced.

FIG. 12 is a flow chart illustrating stages in an example of a processfor treatment of data acquired from electrode.

Example 2

For detection based on direct sensing of periodic movement (vibration),one or more motion sensors, such as an accelerometer, may be applied toany exposed skin region overlying a muscle group engaged in shivering.The sensors may be held in place using an adhesive such as a hydrogel,or by an elastic band. FIG. 11A is a plot (trace) of a data signal froman accelerometer held on the skin of a shivering subject, at a siteoverlying a muscle mass susceptible to shivering (the pectoral muscles).In this demonstration the data were obtained using an accelerometer.FIG. 11B is a plot (trace) of a data signal, obtained in the samemanner, from the same subject following application of counterwarming.FIG. 11C is a plot showing the power spectral density curve derived fromthe data of FIG. 11A by autocorrelation followed by fast Fouriertransform (FFT). A high narrow peak 142 at about 6.75 Hz, and a muchlower peak appears at about 13.3 Hz. FIG. 11D is a plot showing thepower spectral density (PSD) curve derived from the data of FIG. 11Bsimilarly by autocorrelation followed by fast Fourier transform (FFT).Shivering has been substantially reduced; only a very low peak 144 atabout 7.2 Hz remains.

FIG. 13 is a flow chart illustrating stages in an example of a processfor treatment of data acquired from an accelerometer.

Counterwarming according to the invention may be applied for theminimization, prevention, or treatment of shivering such that any of thefollowing pertain.

1. The degree of counterwarming applied may be adjusted according to theamount of cooling being applied to the core at any given moment;

2. The degree of counterwarming applied may be adjusted according to thedegree of shivering measured at a given moment (using for example themethods and apparatus described herein for thequantification/measurement of shivering);

3. The degree of counterwarming applied may adjusted according to thepatient's body temperature as measured by standard methods;

4. The degree of counterwarming applied may be adjusted according to anycombination of: cooling temperature, shivering intensity, and/or patienttemperature with any of a variety of additional variables, constants,proportionality coefficients; or any other mathematical manipulations orinteractions of these variables;

5. The degree of counterwarming applied may adjusted according to therate of change of any of: change in cooling temperature per unit time,change in shivering intensity per unit time, and/or change in patienttemperature per unit time; or any other mathematical manipulation orinteraction of these variables (including but not limited to change inany variable per the square of the unit time);

6. The degree of counterwarming as influenced by any of the abovemethods may be accomplished in any of several different ways, including:changes in the temperature of warming applied to all treated bodyregions; changes in the temperature of warming applied to specifictreated body regions; changes in the pattern of warming applied toselective treated body regions (warming applied to different bodyregions at different times according to any number of patterns);application of warming in a successive fashion to sequential bodyregions (e.g., to ears, then ears+hands, then ears+hands+feet);application of selective warming to smaller regions such as fingers ortoes; or application of warming to different body regions such that aspatial pattern of shivering detected influences the spatial pattern ofwarming applied;

7. The application of warmth to various body regions includes any methodfor application of heat that can be controlled by the methods describedherein, including but not limited to heated mittens, heated booties,heated ear muffs, or heated blankets above or below the body, andincluding but not limited to any conventional method for heat transfersuch as warming with circulating water (or other liquid) or warming byinsulated heating coils;

8. The areas treated with counterwarming may be any exposed body regionnot being used for cooling;

9. The intensity of warmth application to various body regions may beperformed in various patterns with variation of intensity of warmthapplied to different regions and may be used to create gradients ofwarmth;

10. The degree of counterwarming applied may be adjusted according toany number of computer learning algorithms to determine over time anoptimal means of shivering treatment in an individual patient;

The methods in various embodiments can employ any of a variety oftechnical means of body cooling, warmth application, or measurement ofshivering, including but not limited to the method for shiveringquantification described above.

Quantification according to the invention of repetitive adventitialmovements other than shivering can be very useful medically, includingfor example in the measurement and quantification of shaking, tremors,or convulsions. Such information could be particularly useful intracking disease progression, or in tracking effects of medications orsurgical interventions.

Quantification of the motor component of seizures can be particularlyuseful in seizure monitoring settings. Conventionally epilepsy patientsare frequently admitted for monitoring using video EEG telemetry, inwhich the electrical component of the seizures is monitored bycontinuous EEG, but the convulsive movements are captured only by video.Seizure monitoring could be improved according to the invention, byplacing motion detectors (such as accelerometers or ECG or EMGelectrodes) in appropriate locations on the patient's body, andcorrelating the processed signals from motion detectors in real-time ornear real-time with the electrographic seizure activity.

As may be appreciated, shivering may be quantified by processing signalsobtained concurrently from electrodes and from repetitive movement(vibration) sensors, and associations between mechanical movement andelectrical activity can be tracked.

In certain of the signal analysis approaches outlined above,particularly useful in detecting and measuring shivering in a subject, acombined signal including superimposed ECG and EMG components is treatedby identifying and storing epochs based on a feature of the ECGcomponent, averaging the stored combined signal epochs to obtain anaverage ECG signal substantially free of the EMG component, subtractingthe average ECG signal from each of the stored combined signal epochs toobtain isolated EMG epochs, and thereafter further treating the EMGepochs to quantify shivering. At least some of the signal and dataprocessing manipulations are carried out using a machine such as amicroprocessor programmed to carry out the particular manipulations.

As may be appreciated, systems are more generally provided for isolatinga signal of interest from a combined signal containing superimposedfirst and second signals, in certain circumstances. Particularly, wherethe first signal is the signal of interest, the first signal may haveany of a variety of properties; the second signal must include recurringepochs or cycles of a stereotyped waveform, and may in addition have arelationship to an external event, such as an external trigger. Examplesof such signals include, but are not limited to, the recurringelectrical waveform of an electrocardiogram, a repetitive soundwaveform, or a repetitive mechanical vibration.

The process, generally, is as follows.

The combined signal (signal A+signal B) is digitally sampled using astandard analog-to-digital converter at a sample rate sufficient tocapture relevant details of signal A and of signal B. Epochs of thecombined signal (A+B) are then stored in buffers. The initial sample ofeach epoch is determined by signal processing to identify one or morecharacteristic features of the repetitive signal B. For example, ifsignal B has a notable peak, thresholding may be used to identify thepeak in order to utilize the apex of the peak to index the initialsample of each epoch. Any feature of the repetitive and stereotypedsignal B that may be identified by standard signal processing methodsknown in the art may be used to trigger the start of each stored epoch.For example the peak apex itself may be taken as the initial sample ofan epoch; or, the peak may be identified by detecting its apex and someother feature of the peak (or some other feature of the repetitivesignal) may be taken as the initial sample of the epoch. In specificapplications in which signal B also has a temporal relationship to anexternal event, such as an external trigger, the external event may beused to select the start of each epoch, based on the temporalrelationship between the external event and signal B. Typically, eachepoch will last until the sample immediately prior to the first sampleof the next epoch, but shorter epoch durations may be preferable incertain applications. Once a certain number of combined signal (A+B)epochs are stored in buffers, the signals in the buffers are averaged. Asufficient number of epochs are averaged in order to obtain an averagesignal B free of signal A, according to an established method of signalaveraging for noise reduction known in the art, and the results arestored in a new buffer. In order to obtain epochs of signal A havingminimal contamination by signal B, the average Signal B is thensubtracted away from each stored combined signal (A+B) epoch, with theresult of each subtraction stored in a new buffer. The stored isolatedsignal A epochs may then be subjected to desired signal analysis. If theepochs were selected such that each epoch extended until the sampleimmediately prior to the first sample of the following epoch, thesignals may be rejoined end to end to reconstruct the longer recordingof signal A, if desired.

Combined signals of any of a variety of types, from any of a variety ofsources, may be treated in this manner.

Other embodiments are within the claims.

We claim:
 1. A method for treating shivering in a subject in the courseof therapeutic temperature regulation comprising applying activecounterwarming for inhibition of shivering.
 2. The method of claim 1wherein applying active counterwarming operates in a feedback system. 3.The method of claim 1 wherein the therapeutic temperature regulationcomprises applying core cooling to the subject.
 4. The method of claim 1wherein counterwarming is applied in response to quantified shivering.5. The method of claim 1 wherein counterwarming is applied in responseto change in the core temperature of the subject.
 6. The method of claim3 wherein counterwarming is applied in response to the amount of corecooling being applied.
 7. The method of claim 1 wherein counterwarmingis applied in response to a combination of one or more of quantifiedshivering, change in core temperature of the subject, or applied corecooling.
 8. A method for applying active counterwarming to a subjectduring therapeutic temperature regulation of the subject, thetherapeutic temperature regulation including cooling to reduce the coretemperature of the subject, comprising regulating application of warmingto one or more selected sites on the subject's body.
 9. The method ofclaim 8 wherein the selected site includes a body area not used forcooling the core.
 10. The method of claim 8 wherein applyingcounterwarming includes one or a combination of any of: changing thetemperature of warming applied to all treated body regions, changing thetemperature of warming applied to specific treated body regions,changing the pattern of warming applied to selected treated bodyregions.
 11. Apparatus for applying active counterwarming to a subject,comprising apparatus for quantifying shivering in a subject andapparatus for warming selected areas of the patient's body. 12.Apparatus for applying active counterwarming to a subject duringtherapeutic temperature regulation of the subject, comprising apparatusfor quantifying shivering in the subject and apparatus for warmingselected areas of the subject's body, and further comprising apparatusfor cooling the patient to lower the core temperature.
 13. The apparatusof claim 12 wherein the apparatus for cooling the subject comprises atemperature set point feedback device operatively connected to coolingapparatus, and a core temperature sensor operatively connected to thetemperature set point feedback device.
 14. The apparatus of claim 12wherein the cooling apparatus comprises one or more of a coolingblanket, cooling pads, and an endovascular cooling catheter.
 15. Theapparatus of claim 12 wherein the apparatus for warming selected areasof the body includes counterwarming elements, and a counterwarmingcontroller operatively connected to the counterwarming elements andconfigured and adapted to adjust the warming applied to thecounterwarming elements.
 16. The apparatus of claim 15 wherein thecounterwarming controller is operatively connected to one or acombination of two or more of: a core temperature sensor; a core coolingcontroller; and the apparatus for quantifying shivering.
 17. Theapparatus of claim 15 wherein the counterwarming elements includeheating apparel.
 18. The apparatus of claim 15 wherein thecounterwarming elements include one or more of: heated mittens, heatedbooties, heated ear muffs, heated blankets, and heated pads.
 19. Theapparatus of claim 15 wherein the counterwarming elements are heated bymeans for heat transfer.
 20. The apparatus of 19 wherein the means forheat transfer comprise one or more of a circulating warm liquid, orinsulated electrical heating coils.
 21. The apparatus of 15 wherein thecounterwarming elements include apparatus configured for infusion of asuitable warm sterile liquid into the external auditory canals of bothears of the patient.
 22. A method for isolating a first signal from acombined signal containing first and second signals, wherein the secondsignal includes recurring epochs of a stereotyped waveform, by:digitally sampling the combined signal at a suitable sample rate;storing in memory a number of epochs of the combined signal; averagingthe stored epochs of the combined signal to obtain an average of therecurring epochs of the stereotyped second signal waveform; and, using amicroprocessor, subtracting the average recurring epoch from each of atleast a subset of the epochs of the combined signal and storing theresults, containing isolated first signal epochs substantially free ofsecond signal features, in memory.